INTRODUCING: Modified FUE (mFUE)

[Blake Bloxham]

Introducing: mFUE

 

 

What is modified FUE (mFUE)?

 

mFUE is a new approach to the follicular unit extraction (FUE) technique. The goal of the procedure is to create FUT-level results with FUE-level scarring. This means the growth and quality of strip surgery (FUT or FUSS), but without the linear "strip" scar.

 

Why create a new approach to FUE?

 

The FUE technique continues growing in popularity. Patients clearly want FUE. Whether it's the less invasive nature or the lack of the linear scar, hair loss sufferers have spoken!

 

There are serious limitations to the technique, however, and growth and quality of FUE hair is still not on par with strip. But why is this? The best evidence we have available may offer an explanation:

 

*The "blind" approach to FUE graft harvesting creates transection rates as high as 32%.

*The small punches and pulling of grafts during delivery severly "skeletonizes,” or removes the protective tissue layer surrounding follicular unit grafts. According to studies, the growth rate of skeletonized FUE grafts is between 48-68.7%. This means only 1/2 to 2/3rd of all these "skeletonized" FUE grafts grow.

*This same analysis shows that grafts extracted with an appropriate amount of supportive tissue grow 45% better than skeletonized FUE grafts (Reference).

 

So what does this tell us? FUE is becoming very popular, but it may be less efficient and produce more variable results. Hair loss patients only have a finite number of available follicular unit grafts, and each one of these grafts must be optimized and used wisely. We do not believe the FUE techniques available today utilize these precious grafts properly, and wanted to find a way to overcome these issues and deliver the results patients deserve with the minimal scarring they want.

 

From this, we created mFUE.

 

How is mFUE performed?

 

Here is a step-by-step breakdown of the mFUE approach. It highlights the differences between traditional and modified FUE, and explains why we like this method.

 

Please note: all procedural images are taken from experiments with a porcine model. They are not from real patients. Ink is used to make the skin scoring more visible. These may not completely reflect the way these aspects of the procedure look on a real patient.

 

STEP 1: A custom elliptical ("football shaped") punch slightly larger than a traditional FUE punch is used to superficially score (cut) the donor region

 

 

 

 

 

The superficial depth decreases transection and the gentle rocking motion of the punch decreases the torsion and rotation injury associated with the twisting of a traditional FUE punch. The larger size of the tool also ensures that the follicular unit grafts in the center of the punch have a 0% risk of transection. The ability to move and position the mFUE tool creates very minimal transection rates along the border of the punch as well (equivalent to strip transection rates – roughly 1.59%).

 

STEP 2: The physician then grasps the corner of the mFUE graft with forceps, lifts it gently, and uses a needle or blade to dissect it from the donor region.

 

 

 

 

 

This allows for gentle removal of the donor follicles without skeletonization of the grafts, injury to the crucial base (bulb) of the follicles from pulling the grafts,"splaying" of the follicles (which significantly complicates graft placement), or ripping/tearing of the follicular units. This also ensures that 100% of the grafts scored are successfully removed - 100% "attempts made to grafts successfully extracted ratio."

 

STEP 3: The mFUE graft is then handed to a technician who dissects it microscopically into perfect follicular unit grafts.

 

 

 

 

 

This ensures all grafts are ideally shaped for placement and contain the correct amount of supportive surrounding tissue. This significantly decreases the greastest threat to FUE grafts: dehydration.

 

it also creates grafts that look like this:

 

 

 

 

 

and not this

 

 

 

 

 

 

STEP 4: The small (millimeters) defect left behind by the elliptical punch is then closed by primary intention. In other words, it is closed with surgical material. This can be done three different ways: either by staples, which are removed after approximately 10 days (this is the method Dr Feller and I have mainly experimented with); by sutures, which are removed after 10 days as well (this is the method Dr Lindsey prefers); or by a third option: closure with TissueSeal (histoacryl) -- a clear tissue adhesive that requires no suture or staples, no removal, and naturally holds tension equivalent to sutures for the first 7-10 days. The adhesive also serves as an anti-biotic agent, a water-proofing agent, and naturally falls away after the 10 day mark. This option is designed for those who want the traditional FUE post-operative experience or want to return to "normal life" sooner.

 

Here are examples of each closure technique and a comparison to a traditional FUE post-extraction donor region.

 

 

 

 

 

 

 

 

 

Please note: Because the mFUE technique requires a fewer number of extractions, the number of staples or sutures used to close wounds in the donor area is approximately equivalent to the number of staples or sutures required to close a strip wound.

 

STEP 5: The microscopically dissected grafts are then placed in the physician-made recipient sites (the same way they are placed during traditional FUE or FUT/strip surgery)

 

 

 

 

 

What does the donor region scarring look like?

 

Our original goal was to create a procedure with strip-level results without a linear strip scar. Initially, we weren't sure the mFUE scarring would be comparable to the minimal scarring created by traditional FUE. Throughout our clinical testing, however, we were pleasantly surprised with the healed scars.

 

According to most dermatology texts, the size of the wound we create with the mFUE punch is small enough to not require closure by primary intention (sutures, staples, or tissue adhesive). We wanted the best scars possible, however, so we decided to spend the time to close the wounds. Clearly, this made a huge difference.

 

To quote Dr Lindsey, the scarring can be "impeccable!" After viewing the results, I feel this technique exceeded our initial goal of creating strip results without a strip scar, and actually allowed us to achieve “strip results with FUE-level scarring.”

 

Here is an example from Dr Lindsey:

 

"This patient prefers to buzz his sides short, and has had no problem shaving down to the 2 guard he used before surgery."

 

Here is a shot of his donor region.

 

 

 

 

 

Note how the patient has a thinner donor region in general. If you look in the area near his crown, where no mFUE grafts were taken, you'll see it is less dense than we would like. Even with this lower density, the mFUE scars are still, essentially, undetectable.

 

Here are a few more angles (sides of the scalp):

 

 

 

 

 

 

Here is Dr Lindsey showing an mFUE scar up-close.

 

 

 

 

 

Frankly, I still have a difficult time seeing it. I zoomed in 100% and think I found it here:

 

 

 

 

 

What are the benefits/advantages of mFUE?

 

*Strip-quality grafts and strip-level growth yields. This means 98% growth, no skeletonization, no harsh extraction injuries, and no grafts scored with failed delivery.

*Strip quality hair. None of the "wiry" or "kinky" hair we sometimes see from traditional FUE – which is caused by damage to internal root sheath or distortion of the internal follicle.

*FUE-level scarring. No linear scar! Diffuse, very cosmetically acceptable scarring in the donor region like we see in traditional FUE. This allows patients to "buzz" their sides short.

*Hundreds of follicular unit grafts (FUGs) from only a few cuts ("insults") to the scalp. We can extract approximately 100 FUGs with only 5-6 mFUE punches.

*Less "insults" to the scalp means MUCH less of the subcutaneous FUE scarring – which theoretically can make extraction more difficult and decrease yield during future hair transplant procedures.

*Less punches means a significantly smaller number of scars too.

*Ability to undergo larger sessions in a single pass without compromising extraction techniques.

*All manual tools and techniques. Nothing is motorized or automated.

*All extraction is done by the hair transplant surgeon.

*Easier to use for a "hidden" FUE approach -- because only a limited number of small spots need to be shaved for extraction.

*Significantly decreased graft "out of body time" compared to traditional FUE procedures of similar size (meaning even less dehydration).

 

Clearly, we are very excited about this new approach! It took nearly two years to conceive and test, and we -- Dr Feller, Dr Lindsey, and I -- are very excited to finally make the announcement.

 

We are currently offering mFUE sessions up to 1,500 grafts at Feller and Bloxham. I'll let Dr Lindsey expound on his current practices. We are limiting the session sizes temporarily to make sure everything meets our expectations as we move from clinical testing to offering the procedure on a large scale. Eventually, we will start offering larger sessions.

 

This is just our “teaser announcement.” Please stay tuned for more examples of donor scarring and mFUE “before and after” results.

 

Thank you for taking the time to view the post. I look forward to comments and questions!

Edited May 28, 2015 by Blake_Bloxham

[MAGNUMpi]

Very interesting!!

[hairweare]

Sorry Blake but my first impression is that this is step backward using a larger punch in order to achieve what top FUE docs are getting with a .8mm punch. More work, less available donor, and no significant benefits in quality and yield at the expense of possibly unacceptable scarring. The healed donor area shown above is not a result I would be content with myself. I could be wrong but i don't see this method as going anywhere.

[Wwiizzkkiidd24]

Exciting times ahead.

 

I can see this taking over fue in the next coming years.

[Yonex]

how big are the punch sizes with this new tool?

 

my initial reaction would be that it would vastly increase that 'moth eaten' look on the donor area when used for larger sessions

[hairweare]

The advancement of FUE has led to the successful use of punches so small that wounds heal quickly and with minimal to no visible scarring. Extractions that are so large as to require primary closure is a "solution" that is worse that the problem that it intended to address.

[Blake Bloxham]

Yonex,

 

It's difficult to quantify how "big" the tools are for two reasons: 1. we have played around with many slightly different sizes to optimize the number and quantity of the grafts we get with each punch and will still probably use slightly different ones depending on the patient -- like traditional FUE; 2. the punch is elliptical, not round and trying to figure out the surface area is messy -- and I've tried. Haha. I was initially concerned about scarring as well, but it really hasn't panned out that way. The moth eaten appearance is caused in FUE because so many grafts are taken with nothing left in their place besides a circular scar. With mFUE, you need a fraction of the grafts and the scars are closed. This doesn't mean scarring won't occur, but it won't be in the "moth eaten" appearance as long as the individuals sites are closed correctly.

[Michael Vories, MD]

This approach has been tried, and with similar tools. We simply bent 4 mm and 2 mm Miltex punches into an elliptical shape, and also closed the wound with suture. We abandoned this approach because of unacceptable scarring, even with the 2 mm punch.

[KO]

Interesting idea. So this is basically a ton of mini-strips?

[KO]

Dr Vories - since you're here. Could you comment on your protocol for extraction? Do you use manual punches or motorized? Furthermore, do you use the NeoGraft machine to score grafts for extraction?

[Blake Bloxham]

KO,

 

The removal of the mFUE grafts is similar, but they differ from mini strips. Dr Feller actually tried the mini strip approach before, and wasn't happy with the scarring.

 

With mFUE, the punch itself makes it different than harvesting strips, and we've been very pleased with the scarring.

[Blake Bloxham]

Dr Vories,

 

We initially thought someone would have tried this approach along the way. But we searched the literature and found nothing. Did you publish your findings somewhere? The scarring actually surprised us. I wasn't expecting it to heal as well as it did. Wonder what differed?

Edited May 28, 2015 by Blake_Bloxham

[Michael Vories, MD]

We thought of publishing in the ISHRS Forum, but since we did not see this as an advancement, we decided against it. It really all comes down to punch size. We were caught between using larger punches to get the tissue we need, vs. using smaller punches to minimize scarring. In the end, it was our experience with Implanter Pens that erased the need for any of this. The problem is not skeletonized grafts, it is improper placement of skeletonized grafts. I hate banging the same drum, but the lengths physicians will go to get out of the OR (as in tissue placement) just astonishes me.

[Michael Vories, MD]

KO- I love the C*** serrated punches. I use the manual punch holder for some cases, and use the Vortex motorized punch holder on other cases, depending upon the ease of extraction. I manually extract the grafts with inverted curved forceps. We no longer have a NeoGraft machine, due to suction damage to the tissue. Hope that clears that up. Thanks!

[Blake Bloxham]

Dr Vories,

 

I agree that the grafts are skeletonized during extraction with small punches. However, I still haven't seen any conclusive evidence that placement techniques will improve these grafts survival. I tend to think the "damage is done" at that point. Even if they doubt dehydrate or break/become damaged further during placement, studies have shown that, on a biochemical level, the supportive tissue is needed for normal follicle cycling after placement in the scalp.

 

Androgenic alopecia scalp is naturally stripped of good supportive tissue that is needed for the cellular signaling I've mentioned above. Transplanting stripped follicles into deficient scalp deprives follicles of what they need to properly cycle. This is why we advocate for precise microscopic dissection.

 

I suggest taking a look at some of the work from Jahoda and Aaron Gardner regarding the necessary cellular cross talk. Fascinating stuff!

[Dr. William Lindsey]

Blake,

 

Excellent write up. And sure to spark controversy too.

 

Listen...everything has tradeoffs. The informed patient and reputable doctor OUGHT to discuss the tradeoffs with different approaches before any decisions are made. But this is the real world...not everyone is reputable, and not everyone wants to hear the pros and cons of various choices regarding their own health care. I know...I just had a medical procedure 2 days ago, and just filled out the surgerycenter survey listing several things I wasn't told and wouldn't know had I not been a doctor myself. I sympathize with the consumer/patient in wanting all the info to make the best decision I can too!

 

Regarding MFUE, FUE, and Strip:

 

Strip has the advantage of giving you great grafts, even with skinny hair roots because the techs can not skeletonize the root bulbs during dissection. And you can get tons of hair in 20 minutes. The disadvantage is you have a linear scar in the donor region. Some people get bad scars and some doctors are not skilled in closure and sometime you have both of those factors BUT even crappy scars are well concealed with 1/2 inch long hairstyles in almost everyone....and I see a lot of poor scars come in for visits. 80% of those guys with poor scars, who want more hair...tell me to not worry about fixing their scar at all...just give them more hair. So for me, strip works, most people have no trouble with their scar, and it works. Were I getting an HT...I would pick strip. I personally know several HT docs who chose strip for themselves over FUE. That OUGHT to tell people that strip may be the best choice in many, but not all, situations.

 

FUE has the advantage of no linear scar. BUT it has the disadvantage of LOTS of little depigmented scars and frequently lots of subcutaneous donor region scarring that will limit the ease and success of future FUE cases. And like it or not....avulsing the hair out of the scalp does stress the hair. But, its a great option for people who need a true crew cut and who don't need a ton of hair, and who have anything better than fine hairs. I did FUE on my own son...he had a scar and needed hair put in it...didn't want a second linear scar and he has thick wirey hair...FUE is perfect for him.

 

and if you need to understand how fue stresses the roots...particularly in fine hair...watch this video of me working with plants.

 

 

 

Readers...I wish FUE was the end all be all but it isn't. It is great in select circumstances and is ok in most circumstances but its simply not the answer to all of hair's problems. I stumbled across a US surgeon video saying that strip surgery was antiquated and ought to be outlawed.... interestingly he appears to have just gotten into FUE and has no apparent "grown-out" results of his own...but its hype that that that fools many a potential patient into not becoming educated PRIOR to making a decision. That is more of a greedy doctor issue than a duped patient issue but that is another topic.

 

MFUE is simply another approach. It too has advantages and disadvantages that reputable doctors ought to discuss prior to offering or performing it. MFUE has the advantage of giving you really nice grafts...strip quality or almost strip quality...even in fine hair...in a very short period of time, just like strip. It has the disadvantage of giving you a bunch of small linear scars. The guy that Blake shows above that I did, really scarred well. Clearly he scars "ok" with linear scars as he has a couple of small linear scars from trauma over the years sewn up by ER doctors...but they show...his MFUE really are hard, but not impossible to find. (I'll put up a video of his head shortly showing those other scars and this guy in and out doors).

 

Now as of today, I think I've done 28 MFUE cases, starting in Nov 2013. I'm guessing now, but I would guess that I've seen 20 of those people back for scar pics (8 either live away...or despite me begging them to come for scar checks for this novel procedure...they just didn't show). None of the 20 I've seen back have significant scarring. Almost all had some shock loss around the MFUE sites at weeks 4-10, just like strip. All that I have done were closed with one or 2 sutures left in for 10 days...up from the 7 I use for strips. And all got tired of those sutures after a few days....

 

But its a good technique to consider in people who: 1. need a real crew cut 2. are deathly afraid of a linear scar despite reassurances 3. have been all "plugged out" (we've done several guys who had too much scarring for fue and too tight of scalps for strip...and gotten good results with MFUE--I've posted a few and just not said it was MFUE). 4. people who have fine hair 5. need hair for a scar repair and don't want another linear scar 6. and people in whom you just can't extract FUE grafts without unacceptable transectioning.

 

I realize that lots of people will say this is a step backward in HT. I'd suggest it is more of a backstep and counter...to use a tae kwon do analogy from my past. You back up, block and roundhouse so that you can get power...its not a retreat.

 

With proper planning, and closure of the extraction sites...not leaving them open like in the plug days...or simply doing one running suture to close them all poorly...to date we are getting good to excellent scar results. Tension free closing..not putting the sites too close to each other...and 10 days of sutures with vitamin e post suture removal is working at my office so far.

 

It is not perfect...but it has advantages and disadvantages that my weigh out favorably in lots of potential patients. When Dr. Feller and I first started talking about this we both knew it would be threatening to some people, and fools folly to others....but consider strip or near strip quality hair, with limited scarring...and that is an option that warrants consideration.

 

Now let the arguing begin.

 

Good post Blake.

 

Dr. Lindsey McLean VA

[Dr. William Lindsey]

Here are 2 videos of MFUE cases,

 

First is a plugged out donor area that we went in to repair a crown...

 

 

 

 

this is a burn scar who didn't want a linear scar....actually the FIRST one we did.

 

 

and this one is a guy who had a crappy strip scar...went for fue locally which did nothing but leave him poorer and with lots of depigmented 2mm punch scars. we addressed him with MFUE.

 

 

All 3 videos show the donor region with minimal scarring. I am certain that not all of our MFUE patients will scar this well. But, on average, I believe that these scars are decent and worth factoring in the patient's equation on the pros and cons of strip, fue, and mfue.

 

Dr. Lindsey McLean VA

[TakingThePlunge]

Very interesting read Blake! I'm looking forward to viewing more cases.

 

I understand that Dr. Feller prefers closing with staples and Dr. Lindsey prefers sutures but, from my perspective, it seems that TissueSeal would be the best option given it does not require removal. Will this option be at the patient's discretion? Why would this not be the standard method of closure?

[Dr. William Lindsey]

David,

I can't help but swing at that slow ball.

 

You are correct that Dr. Feller likes staples and he's good at them. I prefer sutures, and having put in at least 875,000 sutures, I'm good at them too. Particularly on the face...sutures are as good as it gets. I've had 2 lacerations on my face..both times I numbed myself up and had my friend put in 2 layers of sutures. You'll never convince Dr. Feller to sew, and I'll staple you but charge you more and you'll get a worse scar.

 

But I would strongly caution against tissue glue for skin closure EXCEPT when you have a child with a simple lac that would otherwise require anesthesia/sedation risk to close. I kept it at my house to use on my kids but luckily it wasn't needed and they made it to an age where I can numb them up if they need sutures.

 

When the glue first came out in about 97..I was 2 years out of my fellowship. I did a nonscientific study where I repaired skin cancer defects in 10 sequential patients using a deep layer of sutures (like I use on everyone) and then instead of using sutures in the skin I glued them. Out of that 10....2 looked as good as my "typical" suture closure. 2 got either infected (almost impossible on the face...having done face surgery for 20 years now and having maybe 5 infections) or some type of skin irritation which resulted in certainly a worse scar at 3 months than my typical scars. And the rest looked OK, but nothing that would get me referrals....

 

So like many things in medicine, just because it sounds good on paper does not mean it always works out in real life. I'm certain the glue has advanced, but I'm sticking with sutures.

 

Just my 2 cents.

 

Dr. L

[Michael Vories, MD]

It would seem that one of the distinct advantages that this procedure would have over traditional FUE is the ability to perform the extractions without the mandatory clipping of the donor hair to 1mm length. Can you provide insight to the length of hair required to perform the extractions and the size of the elliptical punch used? Thanks!

[Blake Bloxham]

Dr Lindsey,

 

Excellent write up yourself!

 

You bring up a few more good applications of the mFUE technique: scar repair and removing tough grafts from patients who are "stripped out" or have too much subcutaneous scarring from prior FUE procedures. In fact, I think this is how Dr. Feller first utilized the technique as well -- in a gentleman who wanted FUE, but had too much scarring to deliver the grafts and he had to think outside the box a bit!

 

Thanks for sharing the videos as well. I particularly like the presentation of the young lady with the chemical burn. It really shows the health and durability of the follicles, and it's a great example of what I refer to as "strip-quality hair" in particular -- natural and indistinguishable from the native hairs.

[Blake Bloxham]

Dr Vories,

 

I agree. I hadn't really thought of "long hair FUE," though it could work in this application, but I do think mFUE allows for a nice approach to "hidden" FUE procedures. It definitely offers us the ability to only shave down discrete, small patches in the donor region and only extract a few mFUE grafts from each spot. It will be interesting to experiment with this further!

[ontop]

I'm a novice in this stuff to other members but to me it sounds like more slits & bigger punch sizes.

I'm really trying hard to see where the advange in this method is coming from.

 

Let me re read this topic again, maybe I've missed somthing.

[BUSA]

so wats gonna b the cost of this "New Procedure? how much more time is required to perform? time is money? prices in the states are high enough? does this mean even higher prices then they currently are?

[PupDaddy]

Very very interesting stuff, Drs. Bloxham and Lindsey. Microscopically dissected fu’s from dispersed “micro strips.” Cool! And very creative.

 

Assuming that the quality of the grafts, transection rate, and quality of grown-out hairs generated by mFUE harvesting prove to be essentially equivalent to that of strip (I see no reason in principle why they wouldn’t), I suppose what we’ll all be interested to see is donor scarring for substantial sized cases. I wonder, on average, how many of these dispersed elliptically punched/scored “micro strips” need to be taken for a 1,500 graft transplant, a 2,500 graft transplant, a 3,000-4,500 transplant, etc., how long each tiny straight scar would be, and how the donor area will look after recovering from a large session(s).

 

For what it’s worth, a while back I had about 70 old 90’s mini-grafts punched out from my frontal recipient area and repurposed by a top coalition doc, with the goal of leaving me with a near virgin frontal third to work with for a future restoration. Fairly large punches had to be used to score each of these big multi-hair grafts, and each of the 70 extraction sites were then sutured closed, forming 70 short, thin, linear closed wounds — which I imagine are similar to closed mFUE extraction sites. I was told to expect faint, short white lines as scars. They healed and scarred beautifully. Even with my frontal third shaved slick with a razor, the scarring is all but invisible. If this sort of scarring is comparable to the donor scarring that could be expected from mFUE, I think patients would be at least as happy with it as they would be with the round punctate scarring of traditional FUE, but with strip-level yield and strip-quality matured hair characteristics (if all pans out with mFUE).

 

I had the same question as David about surgical glue as the go-to method for closing the mFUE excision sites, since this would seem to offer such an easy post-op for the patient. Dr. Lindsey answered it from his perspective and provided some interesting first-hand information. Sounds like he’ll go with suturing them, Dr. Feller will staple them, and . . . Dr. Bloxham?

 

Anyway, I am eager to see some full-fledged mFUE restorations. Congrats to Drs. Feller, Bloxham, and Lindsey for trying something different for the benefit of hair loss sufferers. What with proven strip, better FUE protocols and outcomes, pyloscopy in development, and now mFUE, these are heady times (pun intended) for hair transplantation.